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Workplace Incivility as an Extensively Used, But Seldom Defined Concept in Nursing


1 Department of Medical-Surgical Nursing and Operating Room, Faculty of Nursing & Midwifery, Tabriz University of Medical Sciences, Tabriz, Iran
2 Department of Health Services Management, Tabriz Health Services Management Research Centr, Iranian Center of Excellence in Health Management, School of Management and Medical Informatics, Tabriz University of Medical Sciences, Tabriz, Iran
3 Center of Qualitative Studies, Tabriz University of Medical Sciences, Tabriz, Iran
4 Department of Psychiatric Nursing, Faculty of Nursing & Midwifery, Tabriz University of Medical Sciences, Tabriz, Iran
*Corresponding author: Elnaz Asghari, Department of Medical-Surgical Nursing and Operating Room, Student Resarch Committee, Faculty of Nursing & Midwifery, Tabriz University of Medical Sciences, Tabriz, Iran. Tel: +98-4134770648, Fax: +98-4134796770, E-mail: asghariel@tbzmed.ac.ir.
Nursing and Midwifery Studies. 6(2): e41029 , DOI: 10.5812/nmsjournal.41029
Article Type: Brief Report; Received: Aug 22, 2016; Revised: Nov 9, 2016; Accepted: Nov 16, 2016; epub: Nov 21, 2016; collection: Jun 2017

Abstract


Background: Incivility is a prevalent and on rise, but yet vague problem in healthcare settings.

Objectives: This study aimed to explore the perception of nurses about workplace incivility via description of actual experiences.

Methods: This is a qualitative study with a content analysis approach. Participants were 34 nurses selected through purposive sampling. The data was collected using semi-structured interviews and field notes in training hospitals in Iran. The rigor of the study was established by principles of credibility, transferability, dependability, and confirmability.

Results: Data analysis resulted in 975 codes. The classification of the codes resulted in 3 themes. Missed ring in system, working in the shadow of fear, and being scapegoats are the main features to describe the meaning of workplace incivility from the nurses’ perspective.

Conclusions: The finding provided basic information to understand the meaning of incivility. Based on the finding, invisibility, unsafe environment, and the carelessness of the other personnel may be perceived as incivility.

Keywords: Workplace; Violence; Nurses; Qualitative Research; Iran

1. Background


Workplace incivility has been described as “Low-intensity” deviant behavior with ambiguous intent to harm the target (1). Hospital workers generally, and nurses in particular, face high rates of non-fetal workplace assault injuries compared with the workers in other industries (2).


Incivility in workplace may negatively impact retention and recruitment of qualified workers and may diminish the workers’ productivity, performance, motivation, creativity, and organizational commitment (3-6).


The current literature has mainly focused on the frequency, types, related risk factors and consequences of workplace incivility, but there is a lack of studies that explore what nurses see and perceive as workplace incivility (7); and it is vague what manifestation of workplace incivility is. To clarify this basic question, it seems that a qualitative study is needed to recognize the perceptions of nurses about the manifestation of workplace incivility. Exploring such experiences is critical to the development of data-driven effective interventions.

2. Objectives


This study aimed to explore the perception of nurses about the manifestation of workplace incivility.

3. Methods


In this qualitative descriptive design, the participants were 34 nurses working in teaching hospitals of Tabriz, Iran, including two general and five specialty hospitals. They were chosen purposefully. Participants, who had at least 6 months of work experience, were included in the study. To choose the first participants, the researcher asked the nursing offices of different hospitals to introduce a nurse assaulted previously. While analyzing the first three interviews, nurses described some daily experiences of assault or annoyance, but not big enough to report to the nursing office. This helped the researcher in selecting the next participants. The nurses with various background characteristics such as age, sex, work experience, type of the hospital and having any complaint or quarrel with the clients or others were selected.


This study was conducted since April until October 2015. The data was collected through 36 in-depth semi-structured interviews and 8 field notes. The initial question samples were as follows: “what comes to your mind when I say workplace incivility?” and “please describe your experience of workplace incivility”. However, throughout the interview, based on the participant’s response, the probing questions were asked. Since the researcher was faced with some questions during the coding process, two of the participants were interviewed for the second time to clarify the findings. All the interviews were conducted at the participants’ desired time and place. The interviews lasted 45 - 68 minutes. The data collection continued until the researchers reached data saturation; that is, no new concepts emerged from the ongoing data analysis. Interviews were audio-recorded and transcribed before analyzing.


3.1. Ethical Considerations

This study was approved by the ethics committee of Tabriz University of Medical Sciences (tbzmed.rec.1394.123). The purpose and method of the study, confidentiality of the information, and voluntary participation in the study were explained to the participants. The written consent was obtained before starting the interview and implicit consent throughout the observation.


3.2. Data Analysis

The conventional content analysis suggested by Zhang and Wildmuth (8) was used to analyze the interviews. Based on this method, the data was prepared by the verbalization of the transcribed literally as soon, as the first step. In step two, the units of analysis were defined which were mainly a phrase, a sentence, a paragraph, and rarely part of a document or a single word. Then categories were generated inductively from the data using the constant comparative method. To test the coding scheme in the fourth step, the data from three interviews was analyzed simultaneously but separately by two of the researchers. Those codes were compared in the presence of the third researcher. Because the level of consistency was high, the rest of the coding of all texts was done by the corresponding author under the supervision of other team members. In this step, any new themes and concepts emerged from the data were added to the coding manual. After coding the entire data set, the consistency of the coding was rechecked by other researchers, two members and the coder herself again. At the final step, the properties and dimensions of the categories were explored. The data from 8 interviews and one field note were distinctively encoded by two researchers (first author and the corresponding author). Afterwards, the codes were compared with each other at the presence of another researcher. There was more than 90% consistency and similarity between the two researchers’ encodings.


3.3. Data Trustworthiness

Credibility, transferability, dependability and confirmability were considered as the criteria for increasing the study trustworthiness. The credibility of the findings was supported by data triangulation, doing the second interview and having discussions about the findings with the co-authors. The transferability was increased by providing some explanation about the method and analyzing the process and also reviewing the findings by non-involved persons. The dependability was reinforced by the involvement of more than one researcher in the process of analyzing. To provide confirmability, all stages of the study were documented so that it was possible for others to review them (9).

4. Results


There were 21 participants from general hospitals and 13 participants from specialty hospitals. The classification of the codes resulted in 4 subthemes and 3 themes.


4.1. Theme I: Missed ring in system

Although the largest in number, nurses introduced themselves as invisible workforce of the hospitals. Missed ring in system is defined as perceiving discrimination and receiving less value and respect.


4.1.1. Lack of Value

Nurses desired to be seen and valued in the system. Nurses described some experiences in which the attacker, mainly clients, ignored all the labors of the nurses and did not know the real value of the nursing task. An ICU nurse declares her experience as, “After all those round-the-clock quality care, the patient was discharged on foot. He did not at least thank us” (P2, female, 39 years).


Another nurse declares that to discontinue the workplace incivility, at first we expect other nurses, especially in higher positions, to respect us. She gives an example as, “… or when I tell the supervisor we need an extra nurse, she doesn’t accept it, as if it were never important to her” (P17, female, 43 years).


Another nurse compares the value of other personnel, especially the physicians in the clients’ perspective and complains: “The clients feel that we are the doctors’ inferiors and humiliate us … but the worst is that the doctors think the same. They really see themselves as the “boss” of the nurses.” (P22, female, 46 years).


4.1.2. Discrimination

All of the participants complained of discrimination and introduced it as one of the main features of workplace incivility. Nurses declare that they want not as equal benefits as other personnel, but balanced and relevant benefits. A nurse, who is a nursing consul member, too, explains this injustice as, “Although the nurses have greater work load and job-related stress than others, they receive less financial benefits like salary” (P31, male, 42 years).


Another nurse, who had been cooperating with the nursing office previously, describes discrimination as, “those days I tried a lot to change the things for better, but no one accepted my suggestions; however, when a doctor gave exactly mine, they all accepted them” (P32, female, 48 years).


4.2. Theme II: Working in the Shadow of Fear

Nurses need a safe workplace, both physical and mental safety. Working in the shadow of fear explains that they addressed the workplace environment as unsafe because of the high probability of incorrect behavior. Nurses acknowledge the violence and aggressive behavior as eerie and threatening factors. Most of these frights and threats were from clients and especially family members of the patients.


4.2.1. Aggressive Behavior

Nurses described a body of bitter experiences in which although not attacked physically, they were injured spiritually. Loud voice, harsh tone, offensive movements, insult, throwing objects and using vulgar words are among the features of aggressive behavior and, therefore, workplace incivility. An ENT nurse describes the depth of her sadness after an aggressive behavior as: “While I was doing that difficult and painful dressing, the patient insulted ... This was very torturous to me. I told the patient I wished he had slapped me on the face, but hadn’t insulted…” (P14, female, 32 years).


4.2.2 .Violence

Although rare, violence and physical attack were reported in the nurses’ experiences, too. Psychiatric wards and emergency departments nurses were most faced with violence. They classified violence as a reason of working in the shadow of fear. A nurse in the emergency department of a psychiatric hospital describes continuous fear of violence as: “since when I arrive at the ward I think that now an agitated patient may attack me. It is too frequent. I always try to stay in the inner part of the station to be safe” (P1, male, 26 years).


Not only in psychiatric and emergency wards, but also in intensive units, violence has been seen repeatedly. A CCU nurse speaks about the continuous shadow of the fear of incivility in the hospitals and gives an example: “Here the patient in bed 12 quarreled with the supervisor and kicked him” (P4, female, 35 years).


4.3. Theme III: Being a Scapegoat

Nurses speak about most incivilities in which they were not the culprits, but were insulted mainly because of the others. They frequently mentioned that nurses are always available and accessible for clients and other personnel. So, when a person is angry for any reason, it is more likely that he/she will put his/her anger on the nurse.


One of the participants introduces herself as the scapegoats of physicians as, “an unfamiliar man (a family member of the other ward’s patient) entered angrily and just insulted me. He had problems with the doctor. I gave him some water and settled him down, then explained to him what to do; exactly then, the physician passed the ward. He was calm and therefore spoke with ultimate respect to the doctor” (P29, female, 35 years).


Although most of the nurses introduced themselves as the scapegoats of the physicians, some others complained about the systems’ deficit and disorganization, and introduced themselves as the scapegoats of the hospital and the managers. A nurse describes her working experiences in a rural area with minimal facilities as :“I remember a patient’s shouting at me because he was cold and there was not enough blankets…” (P34, female, 49 years).

5. Discussion


The current study is done to clarify the meaning of workplace incivility via nurses’ perception. Missed ring in system shows that nurses do not achieve their desired value. Some health administrators believe that the low quality of care provided with nurses is the main reason of their less value and, therefore, the bad picture of them (10). While others put the guilt on the nursing shortage (11). Literature addresses the root of the lack of value in nursing to the origin of nursing formation. Previously women with low socio-economic conditions were considered as nurses (12); but nowadays nurses are educated persons, so it needs more struggles to conclude.


The second finding, working in the shadow of fear, demonstrates that workplace incivility is an integral element in the culture of the work environment of nurses. Nurses are among those who face many job-related hazards and injuries (13); therefore expecting a safe mental climate in their workplace is the least expectation.


The third finding defines being scapegoats as workplace incivility. Many problems may result in being scapegoats; lack of the general information of people about the responsibility of each official, great work load and nursing shortages are among those conditions which result in incivility.


In conclusion, the finding provided basic information to understand the meaning of incivility. Invisibility, unsafe environment, and being scapegoats because of the carelessness of the other personnel may be perceived as workplace incivility. Highlighting the value of the nurses’ task especially via media, increasing the knowledge of people about the hospital policy and clarifying the responsibility of the hospitals’ officials seem to be helpful in decreasing workplace incivility according to the findings.


The limitation of this study was that we merely investigated the nurses’ ideas. Certainly, investigating the ideas of all the people involved such as patients would reveal more precise results.

Acknowledgments

We thank of the research deputy of Tabriz University of Medical Sciences for providing the permission of this study, and all colleagues for their sincere cooperation despite their being so busy.

Footnotes

Authors’ Contribution: Study concept and design: Farahnaz Abdollahzadeh, Elnaz Asghari, Maryam Vahidi and Hadi Hasankhani, Leyla Doshmangir; gathering data: Elnaz Asghari; analysis and interpretation of data: Elnaz Asghari, Leyla Doshmangir and Hadi Hasankhani; drafting the manuscript: Farahnaz Abdollahzadeh, Elnaz Asghari and Maryam Vahidi; critical revision of the manuscript for important intellectual content: Leyla Doshmangir, Farahnaz Abdollahzadeh, Elnaz Asghari, and Hadi Hasankhani.
Financial Disclosure: None declared.
Funding/Support: The research project was supported by the vice-chancellor of research of Tabriz University of Medical Sciences.

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